0:00

Thank you very much for the kind introduction.

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It's an honor to be here and

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spend the next hour or less than an hour going through a bunch of cases.

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And we're going to go through some cases of pancreatic cyst today.

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I just wanted to show my face for a few minutes so that you could see that I'm

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real here and that I've been in a bright space.

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So I'm going to stop the video, my video, so that you don't get distracted by that.

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But I really look forward to presenting these with you.

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I hope you find them useful.

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And I'm happy to answer as many questions as I can.

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I may not have all the answers,

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but hopefully we can have a dialogue that allows us all to learn a little bit.

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So I'm going to stop my camera,

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share my screen and get going on a handful of cases that I picked out.

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I have about seven cases.

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These are all deidentified, so don't worry if you're seeing any information here.

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This is all scrambled up information

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and I'd like to present the first case to the group.

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So here we go.

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This is going to be this patient over here.

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And so this is, we have a 79-year-old male.

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Again, that age is somewhat accurate, but not the real age for the patient.

1:19

And it's getting an MRI to evaluate a pancreatic lesion.

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So I'm going to go through some sequences

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and we'll have a question pop up when I've gone through some of the sequences

1:29

and we'll see if we can figure out what this is.

1:32

So this is a T2-weighted sequence without fat sat.

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And so a lot of organs to look at, obviously.

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We're going to focus on the pancreas.

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And as I get to it,

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just going to scroll through it one time and scroll through it back up again.

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This is a coronal T2-weighted image.

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Over here, a little bit of motion here and there,

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but you can see the thing that we're looking at over here.

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I don't know about your place,

2:00

MRCP sequence don't always come out too great.

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We try, but they're tough for our patients to take a long time to obtain.

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And so this is the MRCP sequence.

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I'm going to go to the T1 pre-contrast.

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Can see the lesion again over here.

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And then the post-contrast sequence, arterial phase.

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And we have portal venous phase.

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You can see somebody measured it over there.

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I'm going to take out the annotation so you can look at it.

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And then finally, the equilibrium phase over here.

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You can see that lesion.

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I'll be complete and give you the T1 in and out of phase.

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It may not help in this instance, but just to be complete in terms

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of the sequences that we have here.

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Happy to give it.

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You can see this is the out of phase image,

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in phase image. This is the lesion over here.

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And we don't always do diffusion-weighted imaging for pancreatic protocols.

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We try to, but depending on the scanner.

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Doesn't always happen.

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So I'm just going to go straight to the higher b-value and focus

3:01

on that with the ADC images side by side for you to see if you find it very useful.

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So, once again, T2-weighted images over here.

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I'll give you the T1 post-contrast over here.

3:20

That's the lesion in question.

3:22

Can we share the first polling question for the group?

3:27

So in this case, we're asking the most likely diagnosis.

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We've seen it on a bunch of sequences.

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Options that I'm providing for you,

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side-branch IPMN (Intraductal Papillary Mucinous Neoplasm).

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There's a pseudocyst.

3:39

Certainly, always a possibility in the correct context.

3:43

Could it be a cystic neuroendocrine tumor,

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or lymphoepithelial cyst.

3:49

And so, no one thought is a pseudocyst, which is great.

3:53

We have about three votes for side-branch IPMN,

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three votes for cystic neuroendocrine tumor,

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two votes for lymphoepithelial cyst.

4:01

That's a mouthful. So a little bit all over the place.

4:03

So let's go through this.

4:05

So you know what? I think this is a..

4:07

I think, you know...

4:09

Certainly, some of the options that the group picked are very reasonable.

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As long as you can sort of justify why,

4:14

I think that's always a reasonable thing to think about.

4:19

So if we look at this lesion, I just wanted to focus on the two

4:22

sequences that I think are most useful for me in this instance to figure out what

4:26

I think the best diagnosis is in this instance.

4:29

So, there's one thing that it could be

4:30

a whole number of diagnoses, some of which are listed there.

4:33

But what is the best diagnosis?

4:34

Which is the one you think is the best one?

4:36

So we certainly see a cystic mass.

4:38

It's sort of at the center of the tail of the pancreas.

4:40

You can argue body tail junction, but certainly tail of the pancreas.

4:43

You can see the T2 hyperintense, T2 signal internally.

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What I think is important to note in this

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instance and what some of you may have noted is the rim around this lesion.

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So look at this rim.

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As I look at it, it's quite thickened, maybe only a couple of millimeters,

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but even a couple of millimeters for a lesion this big is pretty significant.

5:02

And so, it's almost circumferential, quite thickened.

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When we give the post contrast sequences

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on the T1-weighted images, it was essentially hypointense.

5:10

Look how this rim is really, really enhancing and that it's quite

5:13

thickened, even somewhat nodular in places.

5:15

So when you see that appearance,

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one thing you have to think about is cystic neuroendocrine tumor.

5:21

I'll say that this is an entity,

5:23

which I'm sure a lot of you on this Zoom call know about.

5:26

It's only something that I got more familiar with a couple of years ago.

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And once I sort of recognized the imaging features,

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you know we've been doing pretty good in our group

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of calling these correctly prospectively.

5:40

Let's take a step back and think about neuroendocrine tumors.

5:42

When we think of neuroendocrine tumors,

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we're thinking of these well circumscribed tumors, sharp margins,

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they're not generally ill defined.

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You can draw a nice margin around it.

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You get contrast, they tend to enhance. And some of them,

5:56

if they are large, can have calcifications.

5:58

Generally, you think about function tumors.

6:00

They're smaller, like less than 3 cm.

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The insulinomas,

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the gastronomas.

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The non-functioning ones

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tend to be a little bit larger, about more than 3cm.

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Typically more than 5cm, quite heterogeneous in their appearance.

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And they also have a greater chance of being malignant.

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And then you also have this subset

6:18

of neuroendocrine tumors, these cystic neuroendocrine tumors

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that are good to know about, especially in the context of

6:25

cystic pancreatic masses.

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And the imaging appearance is what I've shown you here,

6:28

that thick peripheral rind.

6:30

When you see the thick peripheral rind that enhances,

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you have to think of the neuroendocrine,

6:33

cystic neuroendocrine tumor.

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Treatment is resection.

6:37

Occasionally, if they're very small,

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some surgeons can enucleate them without doing a big resection.

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But they do have to be taken out.

6:43

In terms of the other options that I provided, side-branch IPMN.

6:47

You know, that's a great thought.

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I mean, most of these things end up being these pesky side-branch IPMNs.

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And for that, the clues to diagnose it prospectively is

6:57

document and communication to the doctor.

6:59

But I haven't seen a lot of side-branch IPMNs with a very thick rind around it.

7:03

So that would be unusual for a side-branch IPMN.

7:05

Pseudocyst, you know, it can look like anything,

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but in this context of pancreatitis would be unusual.

7:11

And lymphoepithelial cyst, I threw that in there.

7:13

It's a very tough to call, prospectively.

7:15

They're very, very rare.

7:17

And the ones that I've seen in the literature just look like cystic lesions.

7:20

And you're never going to really be able to call it prospectively.

7:24

But even the ones that I've seen, don't generally have that

7:27

thick enhancing rim.

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So that's the teaching point here.

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So if you see a cystic mass like this with a thick rind of it enhancement,

7:32

got to think of cystic neuroendocrine tumor.

7:37

That's great.

7:37

So that was the first case that I wanted to share with the group.